HIATAL CLOSURE – NEW TRENDS IN LAPAROSCOPIC ANTIREFLUX SURGERY

HIATAL CLOSURE – NEW TRENDS IN LAPAROSCOPIC ANTIREFLUX SURGERY

F. A. Granderath

• C. T. Frantzides

• M. A. Carlson

1 Department of General Surgery, Hospital Zell am See, Austria

2 Minimally Invasive Surgery Center, Evanston Northwestern Healthcare, Evanston, Il, USA 3 Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA

Fig. 1. Type-I hiatal hernia

Introduction

Gastroesophageal reflux disease ( GERD ) has proven to be the most common upper gastrointestinal disord- er in the western world with 10% of patients having daily symptoms [1], [2]. In many patients, GERD is associated with the presence of a hiatal hernia. The differences between the three traditional types of hia- tal hernia regarding their morphological character- istics as well as the symptomatic correlation with GERD have to be considered. The most compre- hensive classification recognizes three types of hiatal hernias. Type-I hiatal hernias, the classical sliding hia- tal hernias, are characterized by transdiaphragmatic migration of the gastroesophageal junction and the proximal stomach toward the mediastinum. Type-I hi- atal hernias are proven to be most common (80–90%

of all types), particularly when the hernia is small. In type-II hiatal hernias or paraesophageal hernias, the gastroesophageal junction remains below the dia- phragm in its normal position and the gastric fundus herniates alongside the esophagus into the mediasti- num. The type-III hiatal hernias are a combination of both type-I and -II hernias. The gastroesophageal junction is above the diaphragm, and the gastric fundus herniates alongside the esophagus (Figs. 1–3). More than 80% of all paraesophageal hernias are considered to be type-III hiatal hernias.

Depending on these morphological entities, these three types show several symptomatic and clinical differ- ences. A type-I hiatal hernia often causes characteristic GERD symptoms such as heartburn and regurgitation.

Considerations regarding surgical therapy for this hernia type depends on the presence of GERD symptoms;

therefore, the most common indication for surgery in type-I hiatal hernia is persistent GERD symptoms re- calcitrant to medical therapy. A type-II hiatal hernia

also can be accompanied by GERD symptoms, but this hernia type is typically associated with chest pain, dys- phagia, pulmonary problems, nausea or bleeding, which are caused by the gastric herniation. Although paraeso- phageal hernia is a rare condition, it is associated with a rather high incidence of complications.

In case of axial rotation of the gastric fundus, the risk for intrathoracic strangulation and gastric volvulus with eventual incarceration and necrosis is increased.

Therefore, most authors recommend a surgical man- agement of paraesophageal hernia, even in patients without symptoms. The minimally invasive approach to paraesophageal hernia repair has become the stan- dard of care for surgical management of this problem.

Several studies have shown that laparoscopic para- esophageal hernia repair is associated with a lower incidence of morbidity, a shorter hospital stay, and a shorter recovery period compared to open repair [3].

Additionally, most authors agree that the laparoscopic

most common intraoperative finding during redosurgery for the failed antireflux procedure [10].

Some possible patient-related and procedure-related mechanisms for postoperative intrathoracic wrap mi- gration include inappropriate postoperative activities of the patients immediately after surgery, inadequate mobilization of the esophagus, inadequate crural closure secondary to widely spaced crura sutured under tension, or a postoperative rupture of the cruroplasty due to con- tinuous excursion of the diaphragm.

Crural closure has become a relevant problem in laparoscopic antireflux surgery, as well as during laparo- scopic paraesophageal hernia repair. To solve this prob- lem, some authors have advocated the use of prosthetic material for crural closure in both laparoscopic par- aesophageal hernia repair and laparoscopic antireflux surgery. The concept of using prosthetic meshes is based upon the lessening of tension on the hiatal crura or the reinforcement of simple sutured crura to prevent postop- erative hiatal disruption. Since the first description of prosthetic hiatal closure by Kuster in 1993 [5], a number of techniques have been published. There has debate re- garding the shape of the mesh, the material of the mesh, the position and placement of the mesh, and especially whether a prosthetic hiatal reinforcement has to be ten- sion-free. Additionally, there is no agreement regarding the question of selective versus routine use of mesh.

Some authors recommend the routine use of prosthetic mesh in order to prevent tension on the hiatal crura and therefore decrease hiatal hernia recurrence. Other au- thors use mesh selectively, e.g., in patients in whom a approach allows better visibility and higher dissection

of the intrathoracic esophagus. Whether performed open or laparoscopically, however, paraesophageal her- nia repair is associated with a high recurrence rate. Re- cent reports have shown the laparoscopic approach in particular has a higher recurrence rate than the open approach, with recurrence rates in the former up to 42% [4]. Due to this high recurrence rate, several tech- nical details have been considered to minimize the rate of recurrent hiatal herniation. Some of these details are still a matter of controversy; for example the complete removal of the hernia sac, the need to perform an anti- reflux procedure, or the performance of a gastropexy are frequent topics of discussion [5], [6]. The main question, however, has to be whether to perform the hiatoplasty with simple interrupted sutures or with prosthetic material.

During the past few years it has been shown that hi- atal closure also has become a central point in laparos- copic antireflux surgery for GERD [7]. The causes of failure of an antireflux procedure are multiple, but the most frequent cause has proven to be the recurrent hiatal hernia with consecutive intrathoracic herniation of the fundic wrap into the mediastinum [8]. Typical symp- toms of an intrathoracic wrap herniation are persistent or recurrent reflux, dysphagia, or the combination of both. The combination of these symptoms and this ana- tomic complication leads to redo-surgery in most of these patients [9]. In a large review of more than 10.000 laparoscopic antireflux procedures, it was documented that postoperative intrathoracic wrap herniation was the

Fig. 3. Type-III hiatal hernia

Fig. 2. Type-II hiatal hernia

sufficient tension-free hiatal closure cannot be achieved with simple sutures.

For some authors, the indication for reinforcement of the hiatal crura with prosthetic material depends on the size of the hiatal defect. Another point of con- troversy focuses on the shape and material of the prosthetic mesh. Some authors routinely use polypro- pylene meshes for hiatal closure, believing that polypropylene rapidly incorporates and that the de- veloping scar tissue strengthens the muscular fibers of the hiatal crura. Other authors discourage the use of polypropylene due to the development of visceral ad- hesions and the risk of intestinal fistula [11]. On the other hand polytetrafluoroethylene (P TFE) has been recommended for hiatal closure because of its low ad- hesive potential.

Techniques and results of prosthetic meshes for closure of the esophageal hiatus

Several techniques have been described for prosthetic closure of the hiatal crura. Basically, two different approaches have to be differentiated: mesh repair without primary sutured crura (“tension-free”) or mesh repair with primary cruroplasty.

The first study regarding laparoscopic large hiatal hernia repair with hiatal mesh prosthesis was pub- lished by Kuster and Gilroy in 1993 [5]. These authors preferred tension-free anterior repair of the hiatal defect. In 6 patients with large paraesophageal hernia, the hiatal crura could not be sutured anterior to the esophagus without significant tension. There- fore a Mersilene ^® mesh was placed on the hiatus as an anterior onlay patch, overlapping the hiatal crura about 2 cm in all directions. The mesh was secured to the crural edges with staples. No intraoperative or postoperative mesh-related complications occurred during a follow-up period of 8–22 months. Postop- erative gastrointestinal series showed no evidence of postoperative hernia recurrence; however, 2 patients had slippage of a small part of the posterior segment of the fundus. None of these patients developed postoperative mesh-related dysphagia or GERD symptoms during the follow-up period.

A similar technique has been used by Paul et al [12] in 3 elderly patients. A 5  10 cm Gore-tex ^® mesh (PTFE) was cut to cover the hiatal defect,

and then was placed as an anterior onlay patch. The mesh was secured at the lower mesh edges, and then sutured in a running fashion up to the top of the mesh (Fig. 4). In this small series there were no complications, and for a mean follow-up period of 10 months there were no hernia recurrences.

Another technique of tension-free hiatal closure has been avocated by Basso and colleagues [13]. In 65 patients who underwent laparoscopic Nissen fun- doplication with simple sutured hiatal closure the authors experienced a hiatal hernia recurrence rate of 13.8% during a mean follow-up period of 48.3 months. After reviewing the videotapes of these pa- tients, it became clear that the crural sutures were under tension, and that hiatal disruption led to post- operative intrathoracic migration of the fundic wrap.

Due to these findings, the authors began using a 3  4 cm polypropylene mesh for posterior hiatal reinforcement.The mesh was secured with staples on the upper side and on the lateral sides of both crura as a tension free hiatoplasty (Fig. 5). This technique was used in a subsequent group of 67 patients who underwent laparoscopic Nissen fundoplication for GERD . During a mean follow-up period of 22.5 months, the authors saw no complication related to the prosthetic mesh nor hiatal hernia recurrence.

An interesting technique to achieve a tension-free hiatal closure has been described by Huntington et al [14]. If a tension-free crural closure with simple sutures was nor possible, then a relaxing incision on the

Fig. 4. Tension-free anterior repair

diaphragm was performed to gain crural mobility for a simple sutured hiatoplasty. The diaphragmatic defect of the relaxing incision then was closed with a polypro- pylene patch (Fig. 6). This technique was used success- fully in 8 patients with paraesophageal hernia; there was no recurrence during a follow-up period of 8 months.

Champion et al [15] preferred prosthetic reinforce- ment of primarily sutured crura. Similar to Basso et al [13], these authors used a 3  5 cm polypropylene mesh for posterior hiatal closure. After placing interrupted per- manent sutures posteriorly to the esophagus, the poly- propylene mesh was placed as an onlay prosthesis, and then fixed with a hernia stapler along the crural edges.

The mesh was secured further with a centrally placed permanent mattress suture; this ensured that the upper edge of the mesh was positioned at least 1 cm below the upper edge of the crural repair (Fig. 7). This technique was performed in 52 consecutive patients with symp- tomatic GERD and a large hiatal/paraesophageal hernia.

During a mean postoperative follow-up period of 25 months, only one patient developed a postoperative intrathoracic wrap migration; this was caused by violent retching in the recovery room after surgery. Later on, this patient underwent redo-surgery due to recurrent GERD symptoms. Importantly, no mesh migrations or visceral erosion occurred in this series of patients.

In a recently published article by Keidar and Szold [16], the authors use a circular mesh in a similar shape as Frantzides et al [17]. Out of a sample of 33 patients, a group of 10 patients with large paraesophageal hernias underwent laparoscopic prosthetic hiatal repair. The simple cruroplasty then was reinforced with Gore-tex ^® mesh in six patients and Prolene ^® mesh in four patients.

Fig. 7. Sutured crura and posterior mesh repair Fig. 6. Tension-free sutured repair

Fig. 5. Tension-free posterior repair

The mesh was precut to an oval sheet, placed around the esophagus and then fixed to the diaphragm using a hernia stapler (Fig. 8). During a follow-up period of 46–76 months, the satisfaction score was good to ex- cellent in the majority of patients. Only 1 patient of the mesh-repaired patients developed a hiatal hernia recur- rence in contrast to 4 patients who underwent repair without mesh. No complications related to the use of the mesh were seen in this study.

Casaccia et al [18] published their experience with an innovative physiological composite “A” – shaped mesh. The authors first performed a physical and geo- metrical analysis of the esophageal hiatus with a theo- retical model. Based on their findings regarding the physiological strengths of the hiatal crura with or with- out direct sutures, they performed an anatomical study on 20 cadavers to verify the anatomical findings of their theoretical model. As a result, they developed a special

“A” shaped PTFE – mesh ( BARD ^® Composix mesh)

which, when positioned over the hiatal defect, was in- tended to effect closure similar to the physiological con- dition (Fig. 9). In 8 patients with large type-II and type-III hiatal hernia, laparoscopic repair was per- formed with this composite “A” shaped P TFE mesh.

Intraoperatively, the authors found that the mesh fit well in the hiatal region, with good handling and easy placement on the diaphragm. Postoperative dysphagia occurred in 2 patients for up to 3 months after surgery, but no recurrence was observed during an average follow-up period of 8 months.

Based on the possibility of mesh-related complica- tions such as esophageal stricture, mesh migration, or visceral erosion, Oelschlager et al [19] advocated the use of a new type of mesh made from porcine small intes- tine submucosa ( SIS ) for laparoscopic repair of par- aesophageal hernias. The authors closed the hiatal crura with interrupted 20 silk sutures, and then positioned a U-shaped 7  10 cm four-ply Surgisis ^® mesh posteri- orly so that the mesh covered the crural repair. The mesh was secured with interrupted silk sutures to the diaphragm (Fig. 10). This technique has been used in 9 patients with large paraesophageal hernias that could not be closed without tension. In 8 patients who were available for follow-up, only 1 had a small (2 cm) recurrent hiatal hernia on barium esophagram; this recurrence was asymptomatic. Another patient had to undergo pneumatic dilatation for persistent mild dysphagia, but without signs of anatomic failure on endoscopy or barium swallow. There were no other complications in this series.

Another approach to crural closure with biomaterial has been described by Varga et al [20]. In this study, the hi- atoplasty was performed with the ligamentum teres in addition to simple sutures. After closing the hiatal crura with nonabsorbable interrupted sutures, the mobilized ligamentum teres was pulled between the closed crura and posterior esophagus, and then sutured to the crura.

This created a U-shaped hiatal onlay reinforcement (Fig. 11). This technique was performed in 4 patients with type-III hiatal hernia. There were no perioperative complications related to this kind of hiatoplasty. One patient had minor episodic epigastric pain postopera- tively; otherwise, all patients relieved of symptoms. No recurrent hiatal hernia occurred during follow-up of 3–11 months.

Fig. 8. Simple cruroplasty and circular mesh repair

Fig. 9. Simple cruroplasty and “A”-shaped mesh repair

Fig. 10. Simple cruroplasty and SIS

mesh repair

number of sutures depended on the size of hiatal her- nia; in these patients, the crura were approximated with 2–4 interrupted nonbasorbable polyfilament sutures (Figs. 12 and 13).

In the cruroplasty ^and mesh group, the crura were approximated with simple interrupted sutures as above.

Additionally, a 1  3 cm section of polypropylene mesh (cut from a 10  15 Prolene ^® mesh for groin hernia re- pair) was placed on the sutured crura as a posterior on- lay and sutured with one stitch on the lateral sides of both the right and the left crus (Figs. 14 and 15).

Follow-up examinations were performed 6 weeks, 3 months and 1 year after surgery. After 1 year of follow- up, a significant difference in the postoperative occur- rence of intrathoracic wrap migration was found. In the initial group with non-mesh hiatoplasty, a postoperative intrathoracic wrap migration occurred in 6.1% of pa- tients compared to 0.6% of patients who underwent cru-

Fig. 11. Simple cruroplasty and ligamentum teres repair

Own experience

The high rate of postoperative intrathoracic wrap mi- gration after laparoscopic antireflux surgery prompted us to use prosthetic meshes for crural closure in Decem- ber 1998. In all patients who underwent laparoscopic antireflux surgery at our surgical unit, hiatal hernia re- currence with intrathoracic wrap migration was the most common cause of anatomic failure after primary laparoscopic antireflux surgery. In over 70% of patients who underwent laparoscopic refundoplication after pri- mary failed antireflux surgery, intrathoracic wrap migra- tion was found as the reason for failure.

In a prospective non-randomized trial [21] we com- pared 361 patients with GERD who underwent lapa- roscopic Nissen or Toupet fundoplication with simple crural closure to 170 GERD patients who underwent laparoscopic antireflux surgery with simple hiatal clo- sure reinforced with polypropylene mesh. In the group of patients who underwent primary cruroplasty, the

Fig. 12. Simple cruroplasty

Fig. 13. Simple cruroplasty

ral closure with polypropylene mesh onlay. A significant difference also occurred in the incidence of postoperative dysphagia. Patients with mesh-cruroplasty had a dys- phagia rate of 35.3% compared to 19.8% in the non- mesh group 3 months after surgery; however, the dysphagia rate resolved at the 1 year visit and was not different between the two groups.

These findings were re-evaluated in another non ran- domized trial [22], in which 100 GERD patients with simple crural closure were compared to 100 GERD pa- tients with simple closure reinforced with the 1  3 cm polypropylene mesh hiatoplasty. The postoperative dys- phagia rate and its impact on quality of life was evaluated for a period of 12 months after surgery. The postopera- tive dysphagia rate was significantly higher in the mesh- group at 3 month follow-up, but again decreased to

comparable values at 1 year follow-up. Apart from these results, patients quality of life (GQLI) significantly im- proved after surgery in both groups. This improvement remained stable up to one year postoperatively, was com- parable between the two groups, and similar to values from a healthy control group.

To verify these findings, a prospective randomized study was performed on 100 GERD patients scheduled for laparoscopic Nissen fundoplication [23]. Fifty pa- tients were prospectively randomized to laparoscopic 360 floppy Nissen fundoplication with simple hiato- plasty, and fifty were randomized to laparoscopic 360

floppy Nissen fundoplication with 1  3 cm polypro- pylene mesh onlay. Follow-up of 12 months was obtained in all patients. Three months after surgery, a significant difference in postoperative intrathoracic wrap migrations was observed. Five patients (10%) of the non-mesh group had a recurrence compared to 1 patient (2%) of the mesh-group. Twelve months after surgery, the recurrence rates increased to 4 patients (8%) in the mesh-group and 13 patients (26%) in the non-mesh- group. In addition, patients with prosthetic hiatal closure again had a higher dysphagia rate at the 3 months visit, as previously observed.

A different type of prosthetic mesh was used in 24 patients who underwent laparoscopic refundoplication in our surgical unit for a failed primary antireflux sur- gery. The cause of failure in all of these patients was a symptomatic intrathoracic wrap mig-ration [24]. The failed hiatal repair was primarily approximated with in- terrupted nonabsorbable sutures and then reinforced with a circular precut polypropylene mesh. The mesh was cut out with a 3–4 cm “keyhole” as described by

Fig. 14. Simple cruroplasty and posterior 1  3 cm polypropyl- ene mesh repair

Fig. 15. Simple cruroplasty and posterior 1  3 cm polypropylene

mesh repair

the mesh and secured with staples on the lateral side of the mesh (Figs. 18 and 19). The advantages of this mesh type have been ascribed to the combination of two clinically proven materials: BARD ^® mesh on the one side for maximum tissue ingrowth and eP TFE on the other side for minimal visceral adhesions.

In addition, we are participating in a multicenter study regarding the use of PARIETEX ^® , a newer mesh, which, similar to the Composix mesh, combines two dif- ferent materials. Parietex ^® composite mesh has a three- dimensional weave of polyester on the one side with a hydrophilic collagen material on the other side. The re- sorbable collagen side has been designed for the preven- tion of intrabdominal adhesions to the mesh in the early postoperative period. The polyester side guarantees rapid tissue ingrowth with permanent reinforcement. In con- junction with the participating colleagues and the man- ufacturer, we have designed a special “V” shape of this mesh particularly for laparoscopic closure of the hiatal crura. The mesh is used both for tension-free hiatal clo- sure (Figs. 20 and 21) and as an additional reinforcement of primary sutured hiatal crura. Positioned as a posterior onlay prosthesis, the mesh is secured to the diaphragm with a hernia stapler.

Based on our previous findings and experiences, we are developing a new kind of prosthetic mesh which specifically will be for hiatal closure. During laparo- scopic refundoplication for primary failed hiatal clo- sure, the fundic wrap often does not slip posterior to but also anterior to the esophagus. Therefore, in addi- tion to posterior closure, the mesh should also cover the anterior diaphragmatic region to prevent postope- rative anterior slippage. Circular meshes have proven Frantzides and Carlson [25]. The mesh was placed

around the esophagus and secured to the diaphragm and crura with a hernia stapler (Figs. 16 and 17). All patients were followed for 12 months after surgery, and no one had a hiatal hernia recurrence. We have had no evidence of any mesh-related complications such as erosion, mi- gration, or visceral perforation in our patients.

We also are working on other alternatives for hiatal closure. The higher dysphagia rate in patients with hiatal mesh prosthesis has led us to use a special “V”

shaped Composix mesh (Crurasoft ^® , BARD ) for large hiatal hernia repair. After dissection of the hiatal crura, the mesh is brought into the abdomen and positioned on to the crura as a tension-free posterior onlay. The mesh is fixed with interrupted sutures on the edges of

Fig. 16. Simple cruroplasty and circular polypropylene mesh repair

Fig. 17. Simple cruroplasty and circular polypropylene mesh

repair

to be an effective method to prevent hiatal hernia re- currence in some studies. We have employed a “heart”

shaped modification of this mesh with large anterior and posterior portions which completely cover the hi- atal crura behind the esophagus. The esophagus lies in a 3–4 cm central keyhole, which is protected by a PTFE collar to prevent esophageal erosion by the mesh (Fig. 22).

Experience of Drs. Frantzides and Carlson

Our initial results with laparoscopic mesh- reinforced diaphragmatic hernia repair

To our knowledge, Dr. Robert Condon of the Medical College of Wisconsin (Milwaukee, Wisconsin, USA)

was the first to address the problem of unacceptably high recurrence rate after (open) sutured hiatal hernior- rhaphy by using a mesh-reinforced cruroplasty. Begin- ning in the latter 1970’s, this surgeon (who was our mentor) instituted a policy of polypropylene onlay to the diaphragm for patients with large hiatal hernia with intrathoracic stomach [26]. His technique consisted of a sutured posterior cruroplasty onto which a sheet of Marlex ^® was placed, followed by a gastrostomy. In order to accommodate passage of the esophagus, a “keyhole”

was cut in the center of the mesh. Over a fifteen year period, 44 patients with intrathoracic stomach were treated in such a manner. After a mean follow-up period of 52 months (range 2 months to 15 years), the clinical recurrence rate was zero [26]. At the time of its publication in 1998, this manuscript represented one of the largest series of prosthesis-reinforced diaphragmatic hernia repairs, either open or laparoscopic.

Encouraged with the result of open mesh repair of diaphragmatic hernia, we elected to perform the repair with a minimally invasive approach. We did have a con- cern with using a stiff prosthetic mesh (such as Marlex ^® ) at the hiatus, because this mesh did erode into the esophagus in one patient from the open series [26].

Polypropylene mesh erosion into exposed bowel has been a frequent enough problem in mesh repair of an- terior abdominal wall defects, especially in the presence of acute inflammation [27]. We believed that the use of P TFE at the hiatus might lessen the risk for erosive complications, since only a handful of cases have been published documenting P TFE as the cause or suspect- ed cause of a bowel fistula (at the time we were contem- plating such repairs, no reports of erosive complications

Fig. 18. Tension-free posterior Crurasoft

mesh repair

Fig. 19. Tension-free posterior Crurasoft

mesh repair

patients with gastroesophageal reflux disease and large defect hiatal hernia were enrolled into this trial [25]. The study population consisted of a subset of all patients ( 600) undergoing primary minimally invasive antire- flux surgery under the care of Dr. Frantzides. The deci- sion whether to enroll a patient into the study was made after intraoperative measurement of the hiatal defect. If the defect diameter was  8 cm, then the subject was randomized, and a simple posterior cruroplasty with or without P TFE onlay reinforcement (see below) followed by a floppy Nissen fundoplication was performed. After a mean follow-up period of 3.3 years, the recurrence rate in the cruroplasty-only group was 22% (i.e., 8 of 36), and the rate in the cruroplasty plus P TFE group was zero.

There were no mesh-related complications. We con- cluded that P TFE reinforcement of posterior cruroplasty was indicated for hiatal defects  8 cm.

Our technique of laparoscopic mesh-reinforced hiatal hernia repair

Our technique of minimally invasive hiatal hernia repair has been described in detail elsewhere [28]. The patient is placed in a modified lithotomy position with 15–20

of reverse-Trendelenburg tilt, and the surgeon stands be- tween the patient’s legs. We employ five 10 mm ports;

this gives us maximum flexibility in instrument choice, including atraumatic 10 mm tissue graspers (atraugrip grasper – Pilling and Weck Surgical, Ft. Washington, PA). The liver is retracted with an inflatable non- traumatic balloon retractor (Soft Wand atraumatic bal- loon, Southborough, MA). The contents of the hiatal from P TFE could be found). Another theoretical con-

cern we had was whether the use of mesh actually would be of benefit in the repair of diaphragmatic hernia. Our retrospective series suggested that utilization of mesh decreased hernia recurrence rate, but we did not have any controlled data that confirmed this. Therefore, after a small number of cases to demonstrate the feasibility of minimally invasive hiatal herniorrhaphy with P TFE on- lay reinforcement [17], we embarked on a randomized controlled trial to test whether mesh placement reduced the recurrence rate after laparoscopic diaphragmatic hernia repair.

We hypothesized that a benefit from mesh placement most likely would be seen in patients with a large hiatal defect (which we defined as  8 cm). Seventy-two

Fig. 21. Parietex

mesh repair

Fig. 20. Parietex

mesh repair

hernia (stomach, omentum, transverse colon, etc.) are re- duced using the atraumatic grasper. The lesser omentum is then entered at the avascular area above the caudate lobe and the incision extended to the anterior arch of the crura. The hernia sac is reduced and excised. This dis- section of the sac should be done meticulously so that pneumothorax is avoided. We advocate routine excision of the hernia sac; without such excision, the subsequent dissection can be difficult and confusing. The esophagus should be mobilized such that the distal 5 cm lies within the abdomen without tension. We prefer to employ a lighted esophageal bougie during this part of the proce- dure; this can aid in the identification of the esophagus, which can be a difficult task.

After the esophagus is fully mobilized, a posterior cruroplasty is performed with nonpledgeted, interrupted

sutures of braided polyester. If an anterior hiatal defect is present at this point, then we also will a employ a 1–2 stitch anterior cruroplasty. A P TFE patch then is custom-cut from a larger sheet of mesh (see Fig. 23); a

“keyhole” (3.5 cm circular defect) is cut into the center of the mesh to accommodate the esophagus (Fig. 23). The patch is introduced into the abdomen through a trocar (avoiding contact with the skin), and then applied as an onlay to the diaphragmatic repair, ensuring that the ma- croporous (rough) surface of the mesh faces the dia- phragm. The prosthetic is anchored in place with a rigid laparoscopic hernia stapler (see Fig. 24). This 10 mm instrument fires titanium staples; we have found its per- formance optimal for securing PTFE to the diaphragm.

The procedure is completed with a floppy 3-stitch, 2 cm-long Nissen fundoplication, performed over a 50–

60 Fr bougie.

There are issue regarding the technique of mesh fix- ation to the diaphragm; specifically, whether to apply the mesh as on onlay, or to perform a “tension-free” repair.

We have preferred the former; that is, to complete a pri- mary cruroplasty first, and then to cover the cruroplasty with an onlay patch. In this situation, the mesh acts as a buttress for the sutured cruroplasty, relieving the tissue repair from the forces of intraabdominal pressure, respi- ratory excursion, and so forth. In the tension-free repair, the crura are not approximated; the mesh bridges the native defect. At this point in time there is no evidence from the field of mesh hiatal herniorrhaphy to support the use of onlay repair over tension-free repair (or visa versa). Our preference for the onlay repair has been our practice pattern, and we have had and continue to have salutary results from this practice. Practically speaking, it is easier to staple the mesh in place around the esopha-

Fig. 22. The “Zell” mesh

Fig. 23. PTFE onlay patch is constructed to have an oval shape

with a horizontal diameter of 12 cm and anterior-posterior di-

mension of 10 cm. A 3.5 cm “keyhole” is made in the center of the

mesh in order to accommodate passage of the esophagus

The actual firing of the stapler can be a “tricky”

maneuver, because unfortunate stapler deployment can injure the heart, which can result in fatal outcomes [31].

The precise technical details in stapling P TFE to the diaphragm with proximity of the heart are difficult to convey in written form. The surgeon must use enough pressure on the stapler to ensure that the staple pene- trates the prosthesis and secures an adequate tissue bite, but not so much pressure that the staple penetrates the diaphragm and breaches the pericardium. The attain- ment of this skill is facilitated with training, anatomic knowledge, and experience.

Recent results with laparoscopic mesh-reinforced diaphragmatic hernia repair

Since the conclusion of our randomized trial [25] we have routinely employed P TFE mesh reinforcement during minimally invasive repair of large hiatal hernia.

We have decreased our threshold for mesh usage to hiatal defects whose diameter is in the range of 5–6 cm. Our original indication for the utilization of P TFE re- inforcement during hiatal herniorrhaphy was a defect size of  8 cm; this cut-off size is relatively large. Since we had an impressive difference in outcome between the control and mesh groups in our randomized trial [25]

we felt justified in broadening the indication for mesh usage. Since 2000, we have performed 63 minimally invasive hiatal hernia repairs; P TFE was employed in 28 (44%) of these herniorrhaphies. Since 1992 sixty four patients have undergone laparoscopic large hiatal hernia repairs with placement of P TFE prosthesis. We have yet gus when it is surrounded by the sutured crura. In a

small number of cases, it will be impossible to suture the crura together secondary to excessive tension, poor tis- sue, or other reasons. In these situations a tension-free application of the prosthetic should be employed. In the final analysis, it likely is the presence of the mesh itself (and not whether it is applied as an onlay or a bridge) which prevents hernia recurrence.

We believe that in order for the mesh to have an op- timal effect (i.e., producing the lowest possible recur- rence rate), the mesh should cover the repair with a large “overlap”. That is, the mesh should extend beyond the crural margins by as much as the local anatomy will allow (see Fig. B). Practically speaking, extension of the mesh in this location is limited to the right by the infe- rior vena cava, anteriorly by the left lobe of the liver, posteriorly by retroperitoneal structures and to the left by the spleen. Thus caution should be taken to avoid injury to any of these structures. The importance of sev- eral centimeters of mesh extension beyond the entire circumference of a hernial defect has been borne out by a large amount of retrospective data from underlay re- pair of ventral herniorrhaphy, both open and laparo- scopic [29], [30] For example, if a surgeon is faced with a 4 cm round-shaped ventral hernia, then the diameter of the mesh used in an underlay repair typically should be 8–10 cm, which permits a 2–3 cm extension of the mesh beyond the entire circumference of the defect.

While it is difficult to satisfy these same criteria for mesh coverage of a hiatal defect, the precept of mesh overlap of the hernial defect should be kept in mind when applying this technique to a hiatal hernia.

Fig. 24. Completed mesh repair of a hiatal hernia. The crura first

were closed with simple sutures of 2 0 braided polyester, and

then a patch as shown in the previous figure was applied to the

cruroplasty (i.e., as an onlay) and stapled circumferentially in

place. Note the extensive overlap of the repair by the mesh

to document a recurrence after mesh reinforcement of minimally invasive hiatal hernia repair with our tech- nique described above. In addition, no patient has been documented to have mesh infection, erosion, or contrac- tion (“mesh shrinkage” [32]). We have noted in the lit- erature a few reported cases reports of PF TE erosion into a gastrointestinal lumen (see below), but this has not dis- suaded us from using P TFE -onlay reinforcement of su- tured cruroplasty for the repair of the large hiatal defect.

Complications of prosthetic hiatal repair The use of prosthetic materials in surgery for gastro- esophageal reflux disease and/or large hiatal hernia re- pair is accompanied by alow incidence of foreign body complications. For instance, the use of Teflon-pledgets in fundoplication has been associated with visceral ero- sion, foreign body migration, or gastroesophageal fistula after surgery [33]–[35].

In particular, a risk for complications related to the use of prosthetic materials for closure of the hiatal crura has been predicted by some authors. The focus is on the possibility of erosion or migration of the mesh into the esophagus or stomach, as well as compli- cations due to severe mesh adhesions, infection, or the development of fibrotic strictures in the hiatal area. In a study by Carlson et al [26], one patient (2.3%) out of 44 who underwent open prosthetic hiatal closure for large hiatal hernia repair developed a mesh erosion into the esophagus 29 months after surgery. Edelman et al [36] reported one patient out of 5 who had to un- dergo revisional surgery after primary laparoscopic pa- raesophageal hernia repair with mesh. This patients had severe dysphagia due to esophageal stenosis sec- ondary to mesh-induced fibrosis. Likewise, Trus et al [37] also saw one patient who had undergone primary laparoscopic mesh repair for paraesophageal hernia who then suffered from refractory postoperative dys- phagia. During re-laparotomy the authors found a cir- cular scar at the distal esophagus caused by the hiatal mesh. The mesh had to be excised, a myotomy was performed, and then the crura were approximated.

Persistent postoperative dysphagia refractory to dilata- tions was reported by Van der Peet et al [38]. One pa- tient who underwent laparoscopic hiatal hernia repair with Dacron mesh reinforcement had a significant fi- brotic reaction to the mesh; This had to be removed

during a reoperation. Another two patients with mesh-related complications were reported by Casabella et al [39]. One patient developed fibrotic damage at the hiatus postoperatively; the other patient had a mesh erosion into the esophagus. Both of these patients underwent redo-surgery and required distal resection of the esophagus because of the mesh intru- sion into the lumen. Coluccio et al [40] also reported about one case who required resection of the distal esophagus due to a mesh-related complication. This patient underwent large hiatal hernia repair with the use of a P TFE prosthesis which subsequently migrat- ed into the cardial lumen. During reoperation the mesh had to be removed, and the patient required a distal esophageal resection. A fatal complication was described by Kemppainen et al [31]. This patient had a large paraesophageal hernia with acute thoracic herniation and incarceration of the stomach, and underwent laparoscopic hiatal hernia repair with tension-free hiatoplasty using P TFE . Fixation of the mesh was undertaken with a hernia stapler. After surgery, this patient developed a cardiac tamponade caused by a stapler laceration of a coronary vein.

Although there has been a limited number of complications related to prosthetic mesh after lapa- roscopic antireflux surgery or large hiatal hernia repair, some authors recommend the use of bioma- terials or autologous tissue to avoid any risk of com- plication secondary to prosthetic mesh. Varga et al [20] advocated the use of ligamentum teres for reinforcement of the hiatal crura in four patients with a hiatal hernia  6 cm. In a similar way, the successful use of biomaterial has been described by Oelschlager et al [19]. Nine patients underwent lap- aroscopic paraesophageal hernia repair with the use of a porcine small intestine submucosa (SIS) mesh for crural closure to avoid mesh-related esophageal or gastric injury.

Conclusion and future perspectives

In general, hiatal reinforcement with the use pros-

thetic meshes has proven to be a safe and effective

procedure to prevent postoperative hiatal hernia re-

currence and/or postoperative intrathoracic migra-

tion of the fundic wrap in both laparoscopic surgery

for hiatal or paraesophageal hernia repair as well as

Carlson (Omaha, USA) have reduced their original indication of hiatal defect  8 cm to a typical cut-off point of 5–6 cm. Other factors like body mass index or sociodemographic aspects may influence the indi- cation somewhat, but the primary indication for them has remained the size of the hiatus. Dr. Szold (Tel Aviv, Israel) recommends the use of meshes in all patients with paraesophageal hernias, in all hiatal hernias  4 cm, or in patients in whom the crura seem weak or damaged.

Regarding the characteristics of the mesh, most authors agree that the ideal mesh has to be easy to handle during laparoscopy, able to adhere to the diaphragmatic surface on the one side, and be benign to the visceral surface on the other side. It should be resistant to infection and to long-term contraction.

The shape of the mesh is still a matter of con- troversy. Most authors recommend a posterior onlay repair; others have advocated the use of circular pros- theses with good results. This topic will be a matter of future research, especially when long-term results of published series are available. An overview of experts recommendations is shown in Table 2.

in laparoscopic antireflux surgery for gastroesopha- geal reflux disease. A few comparative studies and trials of laparoscopic hiatal closure with simple su- tures versus mesh-hiatoplasty have shown, that pa- tients with a prosthetic hiatal closure had a lower rate of postoperative hiatal hernia recurrences in compar- ison to patients with simple hiatal repair. Some pa- tients with prosthetic hiatal closure, however, suffer from prolonged postoperative symptoms like dyspha- gia or chest pain; Fortunately, this resolves in most of the patients without further treatment. A true complication related to the use of prosthetic mate- rial for hiatal closure is a rare condition when the procedure is performed properly.

A consensus regarding a standard indication for the use of prosthetic mesh for hiatal closure does not exist at this time. Some authors advocate the use of prosthetic meshes empirically only in patients in whom a tension-free crural closure with simple su- tures seems impossible. Some authors, however, em- ploy prosthetic hiatoplasty in a more liberal matter.

These authors agree that the primary indication for

prosthetic hiatal closure should be the size of the hi-

atal defect. Dr. Frantzides (Chicago, USA) and Dr.

Table 1. Results of laparoscopic hiatal hernia repair with mesh prosthesis

Author Publication Patients (n) Mesh type Repair Follow-up Recurrence

(Ref.) (year) (months) rate

Mesh Non- Mesh Non-

mesh mesh

Kuster J Laparoendosc Surg 6 – Mersilene LPEHR 8–22 0 –

[5] (1993)

Pitcher Arch Surg 2 10 PTFE LPEHR(4), – 0 0

[42] (1995) LARS(8)

Odsdottir Surg Endsoc 10 – LARS 8.9 0

[43] (1995)

Edelman Surg Laparosc Endosc 5 – Surgipro LARS – 0

[37] (1995)

Behrns J Laparoendosc Surg 2 10 LPEHR(5), 6 0 0

[44] (1996) LARS(7)

Trus J Gastrointest Surg 1 75 LPEHR(5),  16 5(7%)

[38] (1997) LARS(71)

Huntington J Am Coll Surg 8 – Prolene 8 0

[14] (1997)

Paul Surg Endosc 3 – PTFE LPEHR(2), 10 0

[12] (1997) LARS(1)

Willekes Ann Surg 30 PTFE LARS 0

[45] (1997)

Frantzides Surg Endosc 3 – PTFE LARS  11 0

[17] (1997)

Medina JSLS 2 18 Goretex LPEHR(6), 6–48 0 0

[46] (1998) LARS(14)

Hawasli Am Surg 27 Prolene LARS 1–56 0

[47] (1998)

Carlson J Am Coll Surg 44 – Prolene PEHR 52 0 –

[36] (1998)

Simpson Am Surg 38 – Dacron LARS 15 0

[48] (1998)

Schulz Abstract 161 157 Prolene LARS 2 12

[49] (1998) (1.2%) (7.1%)

Horgan Am J Surg 5 36 LARS 0 0

[50] (1999)

Wu Surg Endosc 6 – Marlex LARS

[51] (1999)

Carlson Dig Surg 15 16 PTFE LARS 12–36 0 3

[52] (1999) (18.8%)

Frantzides Surg Endosc 17 18 PTFE LARS 36 0 3

[53] (1999) (16.6%)

Basso Surg Endosc 67 65 Prolene LARS 22.5–48.3 0 9

[13] (2000) (13.8%)

Hui Am Surg 12 12 Goretex(8), LARS 24–48 0 0

[54] (2001) Marlex(2),

Prolene(2)

(continued )

Table 1 (continued )

Author Publication Patients (n) Mesh type Repair Follow-up Recurrence

(Ref.) (year) (months) rate

Mesh Non- Mesh Non-

mesh mesh

Lambert Pediatr Surg Int 7 Prolene LARS 12 0

[55] (2001)

Livingston Am Surg 10 22 Composix LARS 1–72 0 3

[56] (2001) (13.6%)

Athanasakis Endoscopy 3 7 PTFE LARS 12 0 0

[3] (2001)

Frantzides Arch Surg 36 36 PTFE LARS 6–72 0 8

[25] (2002) (22%)

Meyer Ann Chir 10 PTFE(5), LARS 8–40 0

[57] (2002) Prolene(5)

Kamolz Surg Endosc 100 100 Prolene LARS 12 1 9

[22] (2002) (1%) (9%)

Casaccia Surg Endosc 8 PTFE 8 0

[18] (2002)

Granderath J Gastrointest Surg 170 361 Prolene LARS 12 1 22

[21] (2002) (0.6%) (6.1%)

Morales Springer 9 55 PTFE LARS 1 3

[58] (2002) (1.1%) (5.4%)

Champion Surg Endosc 52 – Prolene LPEHR 7–60 1 –

[15] (2003) (1.9%)

Leeder Surg Endosc 14 39 Prolene LARS 6–89 2 3

[59] (2003) (14%) (7.6%)

Diaz J Gastrointest Surg 9 107 Polene, LARS 30  25 2 19

[60] (2003) SIS (33%) (21%)

Oelschlager Am J Surg 9 – SIS LARS 3–16 1

[19] (2003)

Granderath Arch Surg 24 – Prolene RELARS 12 0

[24] (2003)

Ponsky Surg Endosc 1 21 0

[61] (2003)

Keidar Surg Lap End Per Tech 10 23 Goretex(6), LARS 46–76 1 4

[16] (2003) Prolene(4) (10%) (18%)

Granderath Arch Surg 50 50 Prolene LARS 12 4 13

[23] (2005) (8%) (26%)

T able 2. Exper ts experienc e and r ec ommendations Sur geon M esh t ype Recur- Redo- M esh r elat ed Indication f or pr osthetic Tension-fr ee v s. Ideal mesh? renc es pr oc edur es complications hiatal closur e additional for failed (er osion, sutur es hiatal migration, closur e inf ec tion) F ilipi G or e Dual 0 0 0 (1) W eight  100 lbs Simple sutur es
“C ”-shaped with 4 cm mesh (PTFE) (2) Ph ysical jobs Onla y mesh inner hole (3) Tearing crur a introperativ ely Basso P olypr opylene 1 1 2 migr ations (1) Hiatal def ec t  3 cm Tension-fr ee 3  4 cm polypr opylene (2) W eak pillars (3) Str et ching pillars 6  6 cm polypr opylene for lar ge hernias Sz old G or et e x, 3 3 0 (1) All par aesophageal Simple sutur es
“U” shaped c o v ering the P olypr opylene , hernias Onla y mesh post erior r epair C omposit e (2) Hiatal def ec t  4c m (3) W eak crur a C arlson P olypr opylene , 0 0 1 esophageal (1) Hiatal def ec t  6 cm Tension-fr ee (1) easy t o handle PTFE er osion (2) benign t o visc er al (P olypr opylene) sur fac es (3) resistant t o long- term c ontr ac tion (4) inexpensiv e (5) able t o adher e t o diaphr agma (6) noncar cinogenic F ran tzides PTFE 0 0 0 (1) Hiatal def ec t  5 cm Tension-fr ee O v al shape with (2) poor muscle crur a 3.5 cm k e yhole qualit y

References

[1] Dent J, Jones R, Kahrilas P, Talley NJ (2001) Manage- ment of gastro-oesophageal reflux disease in general prac- tice. BMJ 322: 344

[2] Spechler SJ (1992) Epidemiology and natural history of gastro-oesophageal reflux disease. Digestion 51: 24 [3] Athanasakis H, Tzortzinis A, Tsiaoussis J, Vassilakis JS,

Xynos E (2001) Laparoscopic repair of paraesophageal hernia. Endoscopy 33: 590–594

[4] Hashemi M, Peters JH, DeMeester TR, Huprich JE, Quek M, Hagen JA, Crookes PF, Theisen J, DeMeester SR, Sillin LF, Bremner CG (2000) Laparoscopic repair of large type-III hiatal hernia: objective followup reveals high recurrence rate. J Am Coll Surg 190(5): 553–560;

Discussion 560–561

[5] Kuster GG, Gilroy S (1993) Laparoscopic technique for repair of paraesophageal hiatal hernias. J Laparoendosc Surg 3: 331–338

[6] Perdikis G, Hinder RA, Filipi CJ, Walenz T, McBride PJ, Smith SL, Katada N, Klingler PJ (1997) Laparosopic paraesophageal hernia repair. Arch Surg 132: 586–590 [7] Hunter JG, Smith CD, Branum GD et al (1999) Lap- aroscopic fundoplication failures: patterns of failure and response to fundoplication revision. Ann Surg 230:

595–604

[8] Soper NJ, Dunnegan D (1999) Anatomic fundoplication failure after laparoscopic antireflux surgery. Ann Surg 229: 669–677

[9] Granderath FA, Kamolz T, Schweiger UM, Pointner R (2004) Quality of life, patients satisfaction and surgi- cal outcome after laparoscopic refundoplication: experi- ences with 100 laparoscopic redo-procedures. Surg Endosc (Suppl 18): O212

[10] Carlson MA, Frantzides CT (2001) Complications and results of primary minimally invasive antireflux proce- dures: a review of 10,735 reported cases. J Am Coll Surg 193: 428–439

[11] Ponce JF, Barriga R, Martin I, Morales Conde S, Morales S (1998) Prosthetic materials in incisional hernia. Experimental study. Cir Esp 63: 189–194 [12] Paul MG, De Rosa RP, Petrucci PE, Palmer ML,

Danovitch SH (1997) Laparoscopic tension-free repair of large paraesophageal hernias. Surg Endosc 11: 303–307 [13] Basso N, DeLeo A, Genco A et al (2000) 360 laparo- scopic fundoplication with tension – free hiatoplasty in the treatment of symptomatic gastroesophageal reflux disease. Surg Endosc; 14: 164–169

[14] Huntington TR (1997) Laparoscopic mesh repair of the oesophageal hiatus. J Am Coll Surg 184: 399–401

[15] Champion JK, Rock D (2003) Laparoscopic mesh cru- ro plasty for large paraesophageal hernias. Surg Endosc 17: 551–553

[16] Keidar A, Szold A (2003) Laparoscopic repair of para- esophageal hernia with selective use of mesh. Surg Lap- arosc Endosc 13: 149–154

[17] Frantzides CT, Carlson MA (1997) Prosthetic reinforce- ment of posterior cruroplasty during laparoscopic hiatal herniorraphy. Surg Endosc 11: 769–771

[18] Casaccia M, Torelli P, Panaro F, Cavaliere D, Ventura A, Valente U (2002) Laparoscopic physiologic hiatoplasty for hiatal hernia: new composite “A” shaped mesh. Surg Endosc 16: 1441–1445

[19] Oelschlager BK, Barreca M, Chang L, Pellegrini CA (2003) The use of small intestine submucosa in the re- pair of paraesophageal hernias: initial observations of a new technique. Am J Surg 186(1): 4–8

[20] Varga G, Cseke L, Kalmar K, Horvath OP (2004) Pre- vention of recurrence by reinforcement of hiatal closure using ligamentum teres in laparoscopic repair of large hiatal hernias. Surg Endosc 18: 1051–1053

[21] Granderath FA, Schweiger UM, Kamolz T et al (2002) Laparoscopic antireflux surgery with routine mesh-hiato- plasty in the treatment of gastroesophageal reflux disease.

J Gastrointest Surg 6: 347–353

[22] Kamolz T, Granderath FA, Bammer T, Pasiut M, Pointner R (2002) Dysphagia and quality of life after laparoscopic Nissen fundoplication in patients with and without prosthetic reinforcement of the hiatal crura.

Surg Endosc 16(4): 572–577

[23] Granderath FA, Schweiger UM, Kamolz T, Asche KU, Pointner R (2005) Laparoscopic Nissen fundoplication with prosthetic hiatal closure reduces postoperative in- trathoracic wrap herniation: Preliminary results of a pro- spective randomized functional and clinical study. Arch Surg 140: 40–48

[24] Granderath FA, Kamolz T, Schweiger UM et al (2003) Laparoscopic refundoplication with prosthetic hiatal closure for recurrent hiatal hernia after primary failed antireflux surgery. Arch Surg 138: 902–907

[25] Frantzides CT, Madan AK, Carlson MA et al (2002) A prospective, randomized trial of laparoscopic poly- tetraflouroethylene (PTFE) patch repair vs simple cruro- plasty for large hiatal hernia. Arch Surg 137: 649–653 [26] Carlson MA, Condon RE, Ludwig KA, Schulte WJ

(1998) Management of intrathoracic stomach with polypropylene mesh prosthesis reinforced transabdominal hiatus hernia repair. J Am Coll Surg 187(3): 227–230 [27] Voyles CR, Richardson JD, Bland KI et al (1981) Emer-

gency abdominal wall reconstruction with polypropylene

mesh: short-term benefits versus long-term compli- cations. Ann Surg 194(2): 219–223

[28] Frantzides CT, Carlson MA (2001) Paraesophageal herniation. In: Mastery of surgery, vol. 1 (Baker RJ, Fischer JE, eds). Philadelphia: Lippincott Williams &

Wilkins, pp 721–736

[29] Wantz GE (1991) Atlas of hernia surgery. New York:

Raven Press

[30] Heniford BT, Park A, Ramshaw BJ, Voeller G (2003) Laparoscopic repair of ventral hernias: nine years’

experience with 850 consecutive hernias. Ann Surg 238(3): 391–399; Discussion 399–400

[31] Kemppainen E, Kiviluoto T (2000) Fatal cardiac tam- ponade after emergency tension-free repair of a large paraesophageal hernia. Surg Endosc 14(6): 593 [32] Amid PK (2004) Shrinkage: Fake or Fact? In: Meshes:

benefits and risks (Schumpelick V, Nyhus LM, eds).

Berlin: Springer, pp 198–206

[33] Baladas HG, Smith GS, Richardson MA, Dempsey MB, Falk GL (2000) Esophagogastric fistula secondary to teflon pledget: a rare complication following laparo- scopic fundoplication. Dis Esophagus 13: 72–74 [34] Arendt T, Stuber E, Monig H, Folsch UR, Katsoulis S

(2000) Dysphagia due to transmural migration of sur- gical material into the esophagus nine years after Nissen fundoplication. Gastrointestinal Endosc 51: 607–610 [35] Dally E, Falt GL (2004) Teflon pledget reinforced

fundoplication causes symptomatic gastric and esophageal lumenal penetration Am J Surg 187: 226–229

[36] Carlson MA, Condon RE, Ludwig KA, Schulte WJ (1998) Management of intrathoracic stomach with poly- propylene mesh prosthesis reinforced transabdominal hi- atus hernia repair. J Am Coll Surg 187: 227–230 [37] Edelman DS (1995) Laparoscopic paraesophageal hernia

repair with mesh. Surg Laparosc Endosc 5: 32–37 [38] Trus TL, Bax T, Richardson WS, Branum GD,

Mauren SJ, Swanstrom LL, Hunter JG (1997) Com- plications of laparoscopic paraesophageal hernia repair.

J Gastrointest Surg 1: 221–228

[39] Van der Peet DL, Klinkerberg-Knol EC, Alonso A, Sietses C, Eijsbouts QAJ, Cuesta MA (2000) Laparo- scopic treatment of large paraesophageal hernias. Surg Endosc 14: 1015–1018

[40] Casabella F, Sinanan M, Horgan S, Pellegrini CA (1996) Systematic use of gastric fundoplication in lap- aroscopic repair of paraesophageal hernias. Am J Surg 171: 485–489

[41] Coluccio G, Ponzio S, Ambu V, Tramontano R, Cuomo G (2000) Dislocation into the cardial lumen of a PTFE prosthesis used in the treatment of volumin-

ous hiatal sliding hernia, a case report. Minerva Chir 55: 341–345

[42] Pitcher DE, Curet MJ, Vogt DM, Mason J, Zucker KA (1995) Successful repair of praesophageal hernia. Arch Surg 130: 590–596

[43] Oddsdottir M, Franco AL, Laycock WA, Waring JP, Hunter JG (1995) Laparoscopic repair of paraesophageal hernia. New access, old technique. Surg Endosc 9: 164–168 [44] Behrns KE, Schlinkert RT (1996) Laparoscopic management of paraesophageal hernia: early results.

J Laparoendosc Surg 6: 311–317

[45] Willekes CL, Edoga JK, Freeza EE (1997) Laparoscopic repair of paraesophageal hernia. Ann Surg 225: 31–38 [46] Medina L, Peetz M, Ratzer E, Fenoglio M (1998) Lapa-

roscopic paraesophageal hernia repair. JSLS 2: 269–272 [47] Hawasli A, Zonca S (1998) Laparoscopic repair of

paraesophageal hiatal hernia. Am Surg 64: 703–710 [48] Simpson B, Ricketts RR, Parker PM (1998) Prosthetic

patch stabilization of crural repair in antireflux surgery in children. Am Surg 64: 67–70

[49] Schulz HG (1998) Rezidivrate nach laparoskopischer Antirefluxoperation mit und ohne Prolenenetzplastik bei 318 Fällen – erste Ergebnisse. 7. Jahreskongress der Gesellschaft für Gastroenterologie Westfalen

[50] Horgan S, Eubanks TR, Jacobsen G, Omelanczuk P, Pellegrini CA (1999) Repair of paraesophageal hernias.

Am J Surg 177: 354–358

[51] Wu JS, Dunnegan DL, Soper NJ (1999) Clinical and radiologic assessment of laparoscopic paraesophageal hernia repair. Surg Endosc 13: 497–502

[52] Carlson MA, Richards CG, Frantzides CT (1999) Laparoscopic prosthetic reinforcement of hiatal her- niorrhaphy. Dig Surg 16: 407–410

[53] Frantzides CT, Richards CG, Carlson MA (1999) Laparoscopic repair of large hiatal hernia with poly- tetrafluoroethylene. Surg Endosc 13: 906–908

[54] Hui TT, David T, Spyrou M, Phillips EH (2001) Mesh crural repair of large paraesophageal hiatal hernias. Am Surg 67: 1170–1174

[55] Lambert AW, Huddart SN (2001) Mesh hiatal re- inforcement in Nissen funduplication. Pediatr Surg Int 17: 491–492

[56] Livingston CD, Lamar Jones H, Askew RE, Victor BE, Askew RE (2001) Laparscopic hiatal hernia repair in patients with poor esophageal motility or para- esophageal herniation. Am Surg 67: 987–991

[57] Meyer C, Bufffler A, Rohr S, Lima MC (2002) Le

traitement laparoscopique des hernies hiatales de gran

taille avec mise en place d’une prothese. A propos de

dix cas. Ann Chir 127: 257–261

[58] Morales Conde S, Ponce JF, Morales Mendez S (2002) Paraesophageal hernia: technique and method of fixation a mesh by laparoscopy. In: Laparoscopic ventral hernia repair (Morales-Conded S, ed).

Springer

[59] Leeder PC, Smith G, Dehn TC (2003) Laparoscopic management of large paraesophageal hiatal hernia.

Surg Endosc 17: 1372–1375

[60] Díaz S, Brunt M, Klingensmith ME, Frisella PM, So- per NJ (2003) Laparoscopic paraesophageal hernia re- pair, a challenging operation: medium-term outcome of 116 patients. J Gastroint Surg 7: 59–67

[61] Ponsky J, Rosen M, Fanning A, Malm J (2003) An- terior gastropexy may reduce the recurrence after lapa- roscopic paraesophageal hernia repair. Surg Endosc 17:

1036–1041